FTC gave GRIPA OK, but pay­ers won’t play

Pay­ers hes­i­tant about buy­ing IPA model

Modern Healthcare - - Front Page - Andis Robeznieks

Health­care could look like this.” That’s the trade­marked slo­gan used on the web­site for the Greater Rochester In­de­pen­dent Prac­tice As­so­ci­a­tion. Some might ar­gue that the slo­gan should be: “Health­care could look like this—if only the Greater Rochester In­de­pen­dent Prac­tice As­so­ci­a­tion had some health plan con­tracts.”

GRIPA, an or­ga­ni­za­tion that in­cludes 812 physi­cians and their af­fil­i­ate hos­pi­tals: 494-bed buy it,” said David Nar­row, an at­tor­ney in the health­care di­vi­sion of the FTC Bureau of Com­pe­ti­tion.

The Rochester mar­ket is dom­i­nated by two pay­ers—Ex­cel­lus Blue Cross and Blue Shield and MVP Health Care—and some ob­servers have blamed GRIPA’s small client base on the pay­ers drag­ging their feet. Eric Nielsen, GRIPA chief med­i­cal of­fi­cer, doesn’t nec­es­sar­ily dis­agree. “That’s not wrong, pay­ers have been drag­ging their feet,” Nielsen said, adding that ex­ec­u­tive look­ing else­where now and has sought to “cre­ate di­ver­sity” in the mar­ket by re­cruit­ing three new Medi­care Ad­van­tage plans to do busi­ness in the area and is look­ing to add more self-in­sured large em­ploy­ers, he said.

“We have sev­eral other con­tracts pend­ing,” he said. “We had hoped to get em­ploy­ers to ap­proach the pay­ers and they said, ‘Why bother? Just go to us di­rectly.’ ” Nielsen said about 35% of the com­mu­nity’s physi­cians are af­fil­i­ated with GRIPA, but the IPA con­tract for clin­i­cal in­te­gra­tion is nonex­clu­sive so pay­ers go around the or­ga­ni­za­tion and con­tract in­di­vid­u­ally with its doc­tors.

GRIPA mem­bers use a se­cure, Health In­surance Porta­bil­ity and Ac­count­abil­ity Act of 1996-com­pli­ant physi­cian Web por­tal and data­base to share and store pa­tient in­for­ma­tion—in­clud­ing clin­i­cal data from of­fice vis­its and hos­pi­tal­iza­tions, lab­o­ra­tory re­sults, and di­ag­nos­tic imag­ing, Nielsen said. And, he said, that the data­base is then used to gen­er­ate physi­cian qual­ity re­ports on pre­ven­tive medicine and care man­age­ment ac­cord­ing to physi­cian­cre­ated, ev­i­dence-based guide­lines.

In the­ory and ac­cord­ing to FTC be­lief, this ap­proach will im­prove out­comes and lower costs, but Nielsen ac­knowl­edges their small client base has not yielded enough data to prove their case, which has also hin­dered GRIPA’s growth. “If they in­sist on see­ing out­comes data be­fore the con­tract with us, it’s a Catch-22,” he said. “But we don’t have a lot of data, be­cause we don’t have a lot of mem­bers.”

In con­trast, Oak Brook, Ill.-based Ad­vo­cate Physi­cian Part­ners, which is be­lieved to be the largest clin­i­cally in­te­grated IPA with some 3,400 doc­tors and eight hos­pi­tals, has five years of “value re­ports” posted on its web­site. Ac­cord­ing to the 2010 re­port, the clin­i­cal in­te­gra­tion pro­gram’s asthma out­comes ini­tia­tive saved $16 mil­lion based on na­tional cost av­er­ages and re­sulted in an es­ti­mated 37,920 days saved from ab­sen­teeism and lost pro­duc­tiv­ity. The re­port also states that the or­ga­ni­za­tion’s generic drug-pre­scrib­ing ini­tia­tive saves pay­ers some $14.8 mil­lion an­nu­ally.

Ad­vo­cate Physi­cian Part­ners has con­tracts with 10 pay­ers in the mar­ket. Mark Shields, Ad­vo­cate vice pres­i­dent for med­i­cal man­age­ment, said the group has been en­cour­aged by the FTC to talk about its pro­gram with providers and pol­icy mak­ers. Shields said that doc­tors are not al­lowed by the FTC to work to­gether on set­ting prices for ser­vices—un­less they are shar­ing fi­nan­cial risk or they are clin­i­cally in­te­grated and work­ing to­gether to “add value to the mar­ket­place” by in­creas­ing qual­ity and low­er­ing costs.

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